Hemodialysis, like other invasive health care treatments, is not
without its risks. Patient care incidents and events are numerous and
commonly seen and reported through event tracking mechanisms specific to
individual programs or institutions. Examples of reportable incidents
include medication errors (wrong patient, wrong medication, wrong dose,
wrong time), breach of infection control practices, errors in dialysate
composition, falls, and more. Quality assurance (QA) or Continuous
quality improvement (CQI) programs are often an integral part of
hemodialysis units yet, despite improvements, incidents and errors
continue to be reported. Pressures related to time and staffing appear
to have exacerbated the problem, leading to staff and administrative
concern about this important issue (Tregunno et al., 2009).

Numerous nursing-focused studies have been carried out that have
demonstrated the impact of near misses and patient-level incidents
related to patient health care. For example, Tregunno et al. (2009)
conducted focus groups with direct care providers (nurses) and nursing
leaders to examine the role of the latter in the prevention of
patient-level errors. They revealed the need for a culture of safety--as
defined by the nursing leader--that supports incident reporting while at
the same time encouraging discussion without any fear of repercussions.
The focus here is on using incidents and errors as opportunities for
improvement and for learning, and not for blame.

Moreover, near misses in health care have been described both as
proactive opportunities (to avoid error) and as recovery processes--an
opportunity to change nursing care delivery in order to avoid a negative
outcome. For example, Jeffs, MacMillan and Maione (2009) describe that
screening for, detection of, and management of early stage pressure
ulcers can be viewed as near misses since avoidance strategies or
adjustments to nursing care can prevent complications such as pain,
infection, and even death. In this case, prevention of the complications
equates to avoidance of patient level incidents or errors.

In another study, Jeffs, Affonso and MacMillan (2008) explored the
experiences and perceptions of health care providers (nurses and
pharmacists) and health care consumers about near misses in patient care
and what contributes to their occurrence. This qualitative analysis
revealed a number of themes that were commonly found in
participants' dialogue in the focus group setting. Amongst other
findings, they identified that "Collectively, the current complex
and acute nature of the health care system coupled with the demands put
on the health care team increase the potential for near misses and
errors to occur" (p. 491). Worldwide, there has been a strong
academic focus on the subject of health care and safety. Numerous
resources exist to assist us in providing quality, safe patient care.
For example, organizations such as the World Health Organization (WHO)
have provided guidelines for prevention of errors in health care. Their
Conceptual Framework for the International Classification for Patient
Safety, created in 2009, provides tools that facilitate incident
reporting through standardized definitions and organized template
development based on the existing literature. The WHO document is
intended to standardize safety concepts in health care and facilitate
reporting, analysis, and interpretation of information in an effort to
improve outcomes in patient care. More locally, the Canadian Patient
Safety Institute (CPSI) has recognized the importance of education for
health care professionals about patient safety and their role in
prevention of health care-related errors. Their "Safety
Competencies Framework" provides "a simple, powerful, and
flexible framework that could be integrated smoothly into curricula at
educational institutions, adopted by health care associations and
directly applied in patient care sites across the spectrum of health
care delivery" (Frank & Brien, 2008, p. 2). The CPSI also
delivers the "Safer Healthcare Now!" program, which focuses on
frontline providers and the health care delivery system by providing
education and tools for improving patient safety throughout Canada.
These tools and resources can be found at their website
www.saferhealthcarenow.ca.

From a medication safety perspective, the Institute for Safe
Medication Practices (ISMP) was established in 1975 with a regular
journal column that educated and informed readers about the prevention
of medication errors. ISMP is now a world-renowned organization that
advises in an impartial manner about medication safety practices. Their
website (www.ismp.org) contains information, tools, reporting forms,
access to webinars, and safety alert newsletters. The ISMP will also
carry out consultations to organizations that are interested in a review
of systems and processes with a view to reduce potential for errors.

How safely do we deliver hemodialysis? Besides CQI or QA programs,
we use checklists to verify machine settings during setup, and have
regular equipment checks and calibrations done by our technological
colleagues. In fact, over the years, hemodialysis has become more
complex and sophisticated and, coincidentally, has evolved to be more
strictly regulated and managed from a technological perspective in order
to improve safety and mitigate risk. For example, air detector monitors,
online conductivity monitoring, and blood circuit pressure gauges
(arterial and venous pressure monitors) have all come to exist by way of
necessity and as a result of patient incidents. The age-old adage
resonates here--we learn from our mistakes. Early on, hemodialysis
equipment was not regulated by standards and manufacturing guidelines.
Nowadays, however, hemodialysis equipment must conform to Canadian
Standards Association (CSA) standards that describe and mandate
appropriate parameters for water used for hemodialysis, concentrates
used in delivery of hemodialysis, and dialyzer reuse to name a few.
According to the CSA, their standards in health care "help protect
patients and workers in the health care system by setting minimum
requirements for safety in medical devices, buildings, systems, and
management of professional practices." They also "increase
efficiency in health care facilities and systems without compromising
patient care" (n.d.). Our technologist colleagues can attest to and
educate us on these standards and their meaning to the everyday practice
of maintaining hemodialysis equipment and water treatment systems, along
with numerous other pieces of equipment for which they are responsible.

Despite the regulated technological standards that are intended to
keep our patients safe, patient care examples of near misses or
incidents are numerous in hemodialysis settings. Consider these
scenarios:

Scenario A: Patient A.J. has been ordered to have predialysis lab
work done today. When the RN goes to search the computer for the
results, she cannot find any evidence that blood has been received in
the lab. Shortly thereafter, J.J.'s RN receives a call from the
laboratory advising her of a low hemoglobin level on her patient from a
sample sent predialysis today. She is puzzled, since she did not draw
any lab work on J.J. when initiating his hemodialysis treatment.
Coincidentally, A.J. and J.J have similar surnames and it is presumed
that there has been a mix-up in labelling, either in the hemodialysis
unit, or in the laboratory.

Scenario B: Maria is looking after M.R. today. She has been ordered
to receive an intravenous dose of iron every two weeks on hemodialysis.
When reviewing M.R.'s chart postdialysis, Maria notices that she
inadvertently omitted the dose of intravenous iron today. She revises
the schedule to ensure that the dose will be delivered at the next
hemodialysis session.

Scenario C: Patient S.T. reports to the chair for his hemodialysis
and indicates his predialysis weight to Jane as 74.5 kg. Jane jots down
the number, and is called away to the desk. Robert returns from lunch
break and initiates S.T.'s hemodialysis treatment. About two hours
into the treatment, S.T. becomes severely hypotensive with bilateral leg
cramping. A normal saline bolus and reduction in ultrafiltration rate
are required to resolve the symptoms. On review of the situation, Jane
and Robert discover that Robert misread Jane's handwriting and had
set the target fluid loss at 2 kg higher than the actual target required
to achieve S.T.'s desired postdialysis target weight.

The scenarios are probably not foreign to hemodialysis staff.
However you would define these, as either near misses or adverse events,
these are potentially avoidable missteps in delivery of care. Dr. Alan
S. Kliger described the challenge in a web-based conference hosted by
the ECRI institute in 2008 as follows: "Mistakes are common ... and
are part of our daily lives. The conundrum is that when admitted to ...
a dialysis unit, we expect no mistakes. ... so the real challenge is to
figure out how you bridge that gap" (as quoted in Hogan, 2008).

Kliger and his American colleagues at the Renal Physician's
Association and the Kidney & Urology Association of America, Inc.
surveyed patients and professionals in nephrology in 2006-2007 about
their experiences with errors in nephrology settings. Errors were
commented on in categories such as hand washing, needle insertion,
medication errors, predialysis setup, and falls. Results of the survey
showed that 87% of professionals reported errors had occurred in their
centres within the previous three-month period--and that 59% of those
errors were attributed to lack of adherence to unit procedures.
Twentyseven per cent of patients reported having witnessed a mistake
within the previous three months, and 49% said they worried about a
mistake being made related to their treatment (Hogan, 2008). These are
sobering statistics.

What can we do? Acknowledging the problem is the first step. Taking
measures to improve the culture of safety at both leadership and direct
care levels is also needed. QA or CQI initiatives are clearly
important--but we need to do more. Reviewing unit processes and reducing
pressure on staff that is either self-imposed or imposed by anxious
patients who are keen to get their treatment underway is also important.
Review of documentation tools for clarity and ease of use, use of
electronic charting programs, and use of incident reports as educational
opportunities are additional ways of improving outcomes and reducing
risk. Many operating rooms are now using surgical safety checklists
prior to initiating any procedures. This initiative not only involves
staff, but also involves the patient as part of the health care team.
The "surgical pause" could be a tool revised for use to slow
down the busy hemodialysis team and potentially prevent setup and
initiation errors in hemodialysis patient care.

Finally, researchers have called for efforts--both organizational
and professional--to support nurses engaging in research projects that
advance patient safety practices in clinical settings (Jeffs et al.,
2009). It is time to address some of the more commonly occurring
incidents in hemodialysis care and try to come up with alternative
methods to prevent these incidents. As nurses, we have the
patients' interests at heart--and their safety in our hands. I
challenge you to think outside the box for ways in which you can improve
patient care outcomes in your own hemodialysis units. Why not start
today?

Conceptual Framework for the International Classification for
Patient Safety. (n.d.). World Health Organization. Retrieved from
www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf